The Journal of Emergency Medicine

Editorial Board

2010-02-01

Issue Highlights

2010-02-01

Partial Contents

2010-02-01

A Comparison of Frequent and Infrequent Visitors to an Urban Emergency Department

2008-05-08

Abstract: Frequent visitors account for a high proportion of Emergency Department (ED) visits and costs. Some of these visits could be handled effectively in less expensive primary care settings. Effective interventions to redirect these patients to primary care depend on an in-depth understanding of frequent visitors and the reasons they seek care in the ED. The objective of this study was to explore the differences between frequent visitors and infrequent visitors who seek medical care in one urban ED, as a first step toward developing effective interventions to direct patients to effective sources of care. In structured interviews, we asked 69 frequent visitors and 99 infrequent visitors to an inner-city, adult ED about medical diagnoses, general health, depression, alcohol abuse, physical functioning, self-perceived social support, primary care and ED service use, payment method, satisfaction with their primary care physician, and demographic characteristics. Differences in responses between groups were compared using t-tests for continuous variables and chi-square for categorical variables. Frequent visitors were more likely than infrequent visitors to be insured by Medicaid (53% vs. 39%, respectively) and less likely to be uninsured (13% vs. 24%, respectively) or have private insurance (6% vs. 15%, respectively). They reported higher levels of stress, lower levels of social support, and worse general health status. They were much more likely to screen positive for depression (47% vs. 27%, respectively, p = 0.017). Frequent visitors were more likely to have a primary care physician (75% vs. 66%, respectively), and 45% of the frequent visitors had a primary care physician at the ED hospital compared to 23% of the infrequent visitors. These findings suggest the need to improve access to frequent visitors' primary care physicians, screen them for depression, and offer psychological and social services more aggressively. These findings may apply to other inner city EDs.

Standardization of Severe Sepsis Management: A Survey of Methodologies in Academic and Community Settings

2008-07-24

Abstract: Background: Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies. Objective: The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies. Methods: In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes. Results: Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6–12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively. Conclusions: Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.

Interpreter Services in Emergency Medicine

2008-06-24

Abstract: Emergency physicians are routinely confronted with problems associated with language barriers. It is important for emergency health care providers and the health system to strive for cultural competency when communicating with members of an increasingly diverse society. Possible solutions that can be implemented include appropriate staffing, use of new technology, and efforts to develop new kinds of ties to the community served. Linguistically specific solutions include professional interpretation, telephone interpretation, the use of multilingual staff members, the use of ad hoc interpreters, and, more recently, the use of mobile computer technology at the bedside. Each of these methods carries a specific set of advantages and disadvantages. Although professionally trained medical interpreters offer improved communication, improved patient satisfaction, and overall cost savings, they are often underutilized due to their perceived inefficiency and the inconclusive results of their effect on patient care outcomes. Ultimately, the best solution for each emergency department will vary depending on the population served and available resources. Access to the multiple interpretation options outlined above and solid support and commitment from hospital institutions are necessary to provide proper and culturally competent care for patients. Appropriate communications inclusive of interpreter services are essential for culturally and linguistically competent provider/health systems and overall improved patient care and satisfaction.

Cerebral Venous Sinus Thrombosis in the Emergency Department: Retrospective Analysis of 17 Cases and Review of the Literature

Christopher Fischer, Joshua Goldstein, Jonathan Edlow — 2009-12-23

Abstract: Background: Cerebral venous sinus thrombosis (CVST) is a rare but serious cause of neurologic impairment. Due to its relative rarity, there is limited research that describes the incidence and clinical features of CVST in the emergency department (ED). Objectives: To describe the demographic, clinical, and historical characteristics of patients with CVST who were initially seen in the ED. Methods: This is a retrospective analysis of all patients presenting to three urban, tertiary care hospitals between January 2001 and December 2005 who were diagnosed with CVST. Patients were excluded if they were transferred from other hospitals, or admitted directly to the hospital without evaluation in the ED. We use one representative case to describe the presentation, evaluation, and treatment of CVST. Results: Seventeen patients met the inclusion criteria. Patients had a mean age of 42 years. Presenting complaints included headache (70%), focal neurologic complaints (numbness, weakness, aphasia) (29%), seizure (24%), and head injury (12%). Ninety-four percent of patients had a focal neurologic finding in the ED. A likely contributing cause of thrombosis was identified in all but one patient. More than half of the patients had been evaluated in the ED in the previous 60 days. Two patients died, both as a result of their thrombosis and resulting cerebral infarctions and edema. Of the patients who survived, 80% had a good functional outcome. Conclusions: CVST is rare, but it can have significant associated morbidity and mortality. Whereas the clinical outcome and functional outcomes of treated patients can vary, prompt recognition of the disease is important.

Barium Appendicitis After Upper Gastrointestinal Imaging

Nathan M. Novotny, Keith D. Lillemoe, Mark E. Falimirski — 2008-10-09

Abstract: Background: Barium appendicitis (BA) is a rarely seen entity with fewer than 30 reports in the literature. However, it is a known complication of barium imaging. Objective: To report a case of BA in a patient whose computed tomography (CT) scan was initially read as foreign body ingestion. Case Report: An 18-year-old man presented with right lower quadrant pain after upper gastrointestinal imaging 2 weeks prior. A CT scan was obtained of his abdomen and pelvis that revealed a finding that was interpreted as a foreign body at the area of the terminal ileum. A plain X-ray study of the abdomen revealed radiopaque appendicoliths. Pathology confirmed the diagnosis of barium appendicitis. Conclusions: BA is a rare entity and the pathogenesis is unclear. Shorter intervals between barium study and presentation with appendicitis usually correlate with fewer complications.

A Case Report of a Severe Musculoskeletal Injury in a Wheelchair User Caused by an Incorrect Wheelchair Ramp Design

2008-02-18

Abstract: The Americans with Disabilities Act (ADA) gives all Americans with disabilities a chance to achieve the same quality of life that individuals without disabilities enjoy. In this case report, we will be discussing the consequences of having inaccessible ramps to persons with disabilities that can result in severe musculoskeletal injuries in a wheelchair user. While going down an inaccessible ramp in the garage of a hospital, a wheelchair tipped over, causing a fracture to the user's right femur. The injured patient was taken to the Emergency Department, where the diagnosis of a fracture of the right femur was made. The fracture then had to be repaired with an intramedullary rod under general anesthesia in the hospital. It was discovered that the ramps in the hospital garage did not comply with the guidelines of the ADA. The wheelchair ramps had a ramp run with a rise > 6 inches (150 mm) and a horizontal projection > 72 inches (1830 mm). This led to the redesign and construction of safe ramps for individuals using wheelchairs as well as for pedestrians using canes, within 1 month after the patient's injury, making it safe for wheelchair users as well as pedestrians using the parking facilities. The ADA specifies guidelines for safe ramps for patients with disabilities. It is important to ensure that hospital ramps comply with these guidelines.

Pneumomediastinum After Inhalation of Helium Gas from Party Balloons

Brita E. Zaia, Stephen Wheeler — 2007-11-19

Abstract: A previously healthy 16-year-old boy presented to the Emergency Department with a 2-day history of hoarseness, sore throat, and chest tightness. The physical examination was significant for diffuse neck and chest subcutaneous emphysema. A computed tomography (CT) scan of the neck and chest revealed pneumomediastinum after a plain chest X-ray study failed to uncover this finding. The patient reported that 5 days before presentation he forcefully inhaled helium gas directly from multiple party balloons in an attempt to alter his voice. The patient fully recovered over the next 2 days. Spontaneous pneumomediastinum developed in this patient with no underlying lung disease, presumably from air leakage secondary to the excessive elevation of intra-thoracic pressure due to repetitive inhalation of helium gas. Spontaneous pneumomediastinum remains largely underdiagnosed clinically, especially in young, healthy patients.

Electrocardiogram (ECG) Changes and Cardiac Biomarker Abnormalities Among Two Marathon Runners

Alicia B. Minns, Richard F. Clark — 2008-12-12

Abstract: Background: Marathon running has surged in popularity in the last quarter century. A small percentage of marathon runners develop increases of myocardial-specific markers with exercise, sometimes in the diagnostic range for acute myocardial infarction. A spectrum of abnormal electrocardiogram (ECG) patterns has also been described. Objective: ECG change specifically after marathon running has not been reported and may further the understanding of the interrelation of intense physical exertion and cardiac structure and function. Case Report: Two patients who presented to the Emergency Department on June 3, 2007 after participating in an inner-city full marathon (26.2 miles) with very similar abnormal ECGs that met criteria for acute myocardial infarction were included in this case report. Cardiac biomarker analysis and ECGs were recorded. Both runners were admitted to the hospital and underwent coronary catheterization. One runner (Runner 1) had no coronary artery disease on catheterization and his troponin I peaked at 0.3 ng/mL. The other runner (Runner 2) had 99% occlusion of his left anterior descending artery and his troponin I peaked at 13.4 ng/mL. Conclusion: Previously asymptomatic individuals under extreme physical exertion may be at risk for myocardial stress and myocyte injury. Abnormal ECG patterns in patients under these conditions may not correlate with structural cardiovascular disease.

Is the Intra-Aortic Balloon Pump a Method of Brain Protection During Cardiogenic Shock After Drug Intoxication?

Marianna Janion, Aleksander Stępień, Janusz Sielski, Wojciech Gutkowski — 2008-04-11

Abstract: Cardiovascular medications are ubiquitous and are frequently implicated in accidental or intentional overdose. It is common that combined use of these drugs may lead to hypotension and even shock, followed by metabolic derangements. We report a case in which an intra-aortic balloon pump (IABP) was used in the management of self-poisoning with verapamil, amlodipine, metoprolol, and ibuprofen. In presenting this case of combined massive drug ingestion, we outline early strategy in the Emergency Department and some alternative treatment options. Beyond pharmacological and conservative procedures, we implemented an invasive approach that included temporary pacing, mechanical ventilation, and intra-aortic balloon counterpulsation (IABP). Such intense treatment was necessary due to the critical state of the patient. In our opinion, the use of the IABP contributed to the final recovery of our adolescent patient. Combined mechanical and pharmacological treatment may protect from multi-organ insufficiency, including permanent central nervous system injury. It is hoped that reporting our experience will raise awareness of alternative treatment options for ingestions of cardiovascular medications.

Postpartum Preeclampsia Occurring After Resolution of Antepartum Preeclampsia

Sarah S. Andrus, Allan B. Wolfson — 2008-06-12

Abstract: Preeclampsia is a syndrome characterized by hypertension, proteinuria and edema in a pregnant female after 20 weeks of gestation, including occuring in the postpartum period. Delivery of the infant is usually considered the definitive treatment for preeclampsia. Preeclampsia in a prior pregnancy is associated with an increased risk of recurrence in a subsequent pregnancy. However, it is unusual for preeclampsia to resolve with delivery of the infant and then recur in the same pregnancy in the postpartum period. We present here a case report of a woman who had antepartum preeclampsia treated with delivery. She then had a recurrence of the classic signs of preeclampsia in the postpartum period. Ultimately she was admitted and treated with magnesium with a final diagnosis of recurrent preeclampsia.

Whole Bowel Irrigation and the Hemodynamically Unstable Calcium Channel Blocker Overdose: Primum Non Nocere

Kirk L. Cumpston, Steven E. Aks, Todd Sigg, Erin Pallasch — 2008-07-10

Abstract: Sustained-release calcium channel blocker (CCB SR) overdoses are potentially life-threatening ingestions. These patients may not become hemodynamically unstable until many hours after ingestion. On theoretical grounds, some have suggested that whole bowel irrigation (WBI) with polyethylene glycol electrolyte lavage solution may be of value in the management of these cases. We report two cases with poor outcome (including one fatality) that were complicated by the use of WBI. Both cases were treated with WBI beginning before and continuing after developing hypotension. WBI should be avoided in the setting of the hemodynamically unstable CCB SR overdose.

The Impact of Rapid Sequence Intubation on Trauma Patient Mortality in Attempted Prehospital Intubation

Michael T. Cudnik, Craig D. Newgard, Mohamud Daya, Jonathan Jui — 2008-09-15

Abstract: Background: Rapid sequence intubation (RSI) has been instituted in some prehospital settings to improve the success of endotracheal intubation (ETI); whether RSI improves outcomes is unclear. Objectives: We sought to determine if trauma patients intubated with RSI in the prehospital setting had better survival compared to those intubated without RSI. Methods: Retrospective cohort analysis. We analyzed all injured adults (aged ≥ 15 years) meeting state trauma system criteria, having a prehospital ETI attempt, and transported from the scene (19 counties) to one of the two state Level 1 trauma centers from 2000–2005. To adjust for the non-random selection of patients for field RSI, we built a propensity score from 15 important confounders, including demographics, injury severity, blood transfusion, surgical procedures, comorbidities, alcohol use, transport mode, injury mechanism, and initial field physiologic values. A propensity-adjusted multivariable logistic regression model (outcome = in-hospital mortality), with a time-based variable for system-wide implementation of changes in airway management, was used to test the association between RSI-ETI and mortality. Results: There were 877 consecutive trauma patients who had prehospital ETI during this period and were included in the analysis. Of these, 496 (57%) had RSI-ETI. In univariate analyses, those with RSI-ETI had less severe injuries, better prehospital physiology (i.e., higher Glasgow Coma Scale score and blood pressure), fewer operations, fewer blood transfusions, and lower unadjusted mortality than those intubated without RSI. However, in the propensity-adjusted model, there was no statistical difference in mortality between the two groups (odds ratio 0.74, 95% confidence interval 0.52–1.06). Conclusions: Patients selected for RSI-ETI were less seriously injured, with better prognostic factors than intubated patients for whom RSI was not used. After adjusting for these differences, use of prehospital RSI-ETI was not associated with improved survival.

Fire Jumpers: Description of Burns and Traumatic Injuries from a Spontaneous Mass Gathering and Celebratory Riot

Eric R. Hawkins, Jane H. Brice — 2009-02-17

Abstract: Background: On April 3 and 5 of 2005, approximately 52,000 people gathered in Chapel Hill, North Carolina to celebrate the National Collegiate Athletic Association Final Four victories of the University of North Carolina men's basketball team. As crowds rejoiced and intensified into a celebratory riot, many participants lit dozens of bonfires and expressed themselves by jumping through the flames. Objective: To describe the interesting injury mechanism of celebratory fire jumping and to describe the injuries associated with two celebratory riots. Methods: We conducted a cross-sectional study analyzing all Emergency Medical Services (EMS) and hospital reports of injuries associated with each gathering. We used a standardized data collection instrument to record descriptive information on all patients with celebration-associated complaints and noted their treatment and disposition. For analysis, we abstracted data and generated basic descriptive statistics and comparisons of groups. Results: A total of 58 celebrants received medical care, including 27 patients first evaluated by EMS and 49 patients subsequently evaluated in the Emergency Department. Most were young (average age = 23.8 years), male (65%, 32/49), had complaints associated with alcohol (65%, 32/49), and were not admitted to the hospital (92%, 45/49). Of those presenting for hospital evaluation, 30% (15/49) had burns associated with fire-jumping. Conclusions: Most patients from these gatherings had relatively minor injuries or medical complaints. However, burns associated with fire-jumping represented a substantial proportion of more serious injuries and hospitalizations. These cases are presented to increase awareness of the burn injuries associated with this type of celebratory mass gathering.

Teleradiology Interpretations of Emergency Department Computed Tomography Scans

Timothy F. Platts-Mills, Gregory W. Hendey, Brian Ferguson — 2008-09-24

Abstract: Background: Teleradiologist interpretation of radiographic studies during after-hours Emergency Department (ED) care has the potential to influence patient management. Study Objectives: We sought to characterize frequencies of discrepancies between teleradiology and in-house radiology interpretations for computed tomography (CT) scans. Methods: We conducted a prospective observational study comparing teleradiologist and in-house radiologist interpretations of CT scans obtained between 7:00 p.m. and 7:00 a.m. from the ED at a Level I trauma center. For each scan, discrepancies were characterized as major, minor, or no discrepancy. Follow-up data were used to characterize major discrepancies. Results: Of 787 studies sent to teleradiology, 550 were scans of the head, cervical spine, chest, or abdomen and pelvis. Major discrepancies were identified in 32 of 550 studies (5.8%; 95% confidence interval 4.1%–8.1%), including 7 of 160 head CT scans, 1 of 29 cervical spine CT scans, 3 of 64 chest CT scans, and 21 of 297 abdominopelvic CT scans. We attributed 8 of the 32 major discrepancies to a teleradiology misinterpretation, with one case leading to an adverse event. Conclusions: We identified major discrepancies due to teleradiologist misinterpretation in 8 of 550 studies, with one patient suffering an adverse event. Our findings support the cautious use of teleradiology interpretations.

Rupture of the Pectoralis Major: A Case Report and Review

Kohei Hasegawa, Joel M. Schofer — 2008-09-26

Abstract: Background: Rupture of the pectoralis major muscle is a rare clinical entity that is becoming more common due to the increasing popularity of weightlifting and recreational sports. Due to the rarity of this condition, it may be missed at initial presentation and inappropriately treated, potentially leading to increased disability. Objectives: This case highlights the mechanism of injury, clinical features, diagnosis, and treatment of rupture of the pectoralis major. Case Report: The patient was a 31-year-old male bodybuilder who presented to the Emergency Department with acute pain and swelling in the left axilla after performing a bench press with a 400-pound barbell. The diagnosis of pectoralis major rupture was suspected and confirmed by magnetic resonance imaging, and early surgical repair was performed. Conclusion: The most common mechanism of injury is excessive tension on a maximally contracted pectoralis major muscle. Weightlifting, specifically bench pressing, is a common cause. The diagnosis can usually be made based on a patient's history and physical examination, but shortly after injury, the diagnosis may be obscured by severe pain and swelling. Magnetic resonance imaging is the imaging modality of choice when the diagnosis remains unclear, and can avoid surgical delays. Early diagnosis and treatment within 3 to 8 weeks after the injury has the advantage of avoiding adhesions and muscle atrophy, and can prevent a delayed return to normal activities. Given the trend toward improved results with early surgical repair of complete rupture, it is important to raise awareness about pectoralis major muscle injury among Emergency Physicians to prevent missed or delayed diagnosis and repair.

Revolutionary Advances in the Management of Traumatic Wounds in the Emergency Department During the Last 40 Years: Part II

2009-03-09

Abstract: Background and Objectives: During the last four decades, our research team has devised advances in wound repair that are highlighted in Part II of this collective review. Discussion: There are several different methods to provide an accurate and secure approximation of the skin edges—sutures, tapes, staples, and tissue adhesives. Ideally, the selection of the wound closure technique will be based on the biologic interaction of the materials employed, tissue configuration, and biomechanical properties of the trauma wound. Selection of the appropriate wound dressing is another important consideration in the management of the trauma wound. Conclusion: On the basis of the comprehensive research and clinical studies, we have individualized the wound closure techniques for traumatic wounds so that healing can be achieved with more aesthetically pleasing scars.

An Unusual Cause of Severe Dyspnea: Diastolic Dysfunction Due to Calcific Constrictive Pericarditis

Joseph Novik, Anthony J. Weekes — 2009-02-23

Abstract: Background: Constrictive pericarditis is a rare cause of dyspnea. This disease shares many signs and symptoms with other causes of cardiac failure as well as gastrointestinal and renal diseases, making it difficult to diagnose. Case Report: We present a case of a 73-year-old woman who presented to our Emergency Department (ED) in respiratory failure after a recent history of worsening dyspnea. Constrictive pericarditis was strongly suspected on bedside ultrasonography. Computed tomography scan showed extensive pericardial calcifications and large pleural effusions, supporting the diagnoses. The patient was admitted for treatment and evaluation of constrictive pericarditis, but died of complications during cardiac catheterization. Conclusions: The etiology and physiology of constrictive pericarditis are reviewed and an ultrasound-centered approach to undifferentiated dyspnea in the ED is discussed.

Emergency Ultrasound Usage Among Recent Emergency Medicine Residency Graduates of a Convenience Sample of 14 Residencies

Anthony J. Dean, Michael J. Breyer, Bon S. Ku, Angela M. Mills, Jesse M. Pines — 2008-08-26

Abstract: Background: Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown. Objectives: We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings. Methods: Graduates from 14 EM residency programs in 2003–2005 were surveyed on their current practice setting and use of EMBU. Results: There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported “high use” of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was “not enough time” (61%). Conclusions: Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common.

An Unanticipated Complication of a Novel Approach to Airway Management

Michael Lutes, Daniel J. Worman — 2009-01-16

Abstract: Background: The King LT (King Systems Corporation, Noblesville, IN) is a rescue airway device that is gaining favor in the pre-hospital setting. Unlike other rescue airway devices, such as intubating laryngeal mask airways, the King LT does not allow for the placement of an endotracheal tube through the device. Emergency physicians who receive patients with the King LT in place will be presented with the challenge of converting to a definitive airway. Methods: We attempted a strategy that would allow for conversion from the King LT to the endotracheal tube using a gum elastic bougie. During an airway skills maintenance session utilizing non-embalmed cadavers, Emergency Medicine faculty attempted to convert a King LT to an endotracheal tube using a gum elastic bougie. Results: The technique was not successful, and in fact, resulted in an unanticipated complication. Conclusion: We cannot recommend using the gum elastic bougie as an aid to convert the King LT to an endotracheal intubation based on our experience with a non-embalmed cadaver.

Rapid Diagnosis of Acute Bacterial Meningitis: Role of a Broad Range 16S rRNA Polymerase Chain Reaction

2008-09-15

Abstract: Background: Acute bacterial meningitis is a significant cause of morbidity and mortality throughout the world. It can be difficult to diagnose, as the symptoms and signs are often non-specific. Study Objective: To evaluate the performance of an in-house semi-nested polymerase chain reaction (PCR) assay targeting the 16S rRNA gene of Eubacteria for the rapid diagnosis of acute bacterial meningitis using cerebrospinal fluid (CSF) specimens. Methods: A total of 112 CSF samples from 112 patients were used in the study. Among these, 32 samples were obtained from confirmed cases of Streptococcus pneumoniae, six samples were obtained from confirmed cases of Haemophilus influenzae, one sample from a confirmed case of Neisseria meningitidis, and 10 cases of clinically suspected acute bacterial meningitis. The remaining 63 CSF samples were obtained from patients with non-infectious illnesses (n = 47) of the central nervous system (CNS) and autopsy-confirmed tuberculous meningitis (n = 16). Results: The assay had an overall sensitivity of 93% (95% confidence interval [CI] 0.81–0.98, negative predictive value = 95%) and a specificity of 98% (95% CI 0.92–1.0, positive predictive value = 98%). Conclusion: These preliminary findings suggest that the semi-nested PCR assay targeting the 16S rRNA gene may be used as a rapid test for the diagnosis of acute bacterial meningitis.

Emergent Complications of the Newer Anticonvulsants

Jeffrey F. Wade, Chat V. Dang, Lowell Nelson, Jonathan Wasserberger — 2008-09-01

Abstract: Background: Multiple new anticonvulsants have been introduced recently and they are supplanting the older medications. Whereas the older drugs have well-recognized side effects, both in typical therapeutic doses and in overdosage, the properties of the newer ones are unique and largely unknown to all but sub-specialists. Objectives: This article gives a concise overview of the potential complications of these new medications in both therapeutic use and overdose. Discussion: Clinically significant side effects of the new anticonvulsants, such as metabolic acidosis from topiramate, autoimmune reactions from lamotrigine, hyponatremia from oxcarbazepine, or psychosis from levitiracetam can cause serious morbidity and mortality if unrecognized. The effects of these medications in overdose are also largely unknown to most emergency physicians. Conclusions: This article reviews the major potential side effects of the new seizure medications and the treatment of their overdoses for the practicing emergency physician.

Cerebral Venous Thrombosis

Karen C. Albright, William David Freeman, Brian T. Kruse — 2008-07-10

A 26-year-old African-American woman presented to our Emergency Department due to acute-onset severe headache accompanied by vomiting. She denied a history of migraine, trauma, fever, neck stiffness, alteration of vision, or seizures. She reported a prior history of two miscarriages. She was on no oral medications; however, she used a systemically absorbed vaginal ring contraceptive. She denied tobacco use. On examination she was afebrile with a mildly elevated blood pressure (148/78 mm Hg) and was lethargic. Her neck was supple. Cardiopulmonary examination was normal. Neurologic examination was non-focal with no papilledema. Laboratory values were normal with the exception of mildly elevated platelet count of 586,000 (normal 150–450). Non-contrast head computed tomography (CT) () and magnetic resonance imaging (MRI) () and venogram (MRV) () studies were performed. The patient was anticoagulated with heparin, switched to warfarin orally, and had no neurologic deficits.

Pelvic Ultrasound in Acute Appendicitis

Edward R. Melnick, John R. Melnick, Bret P. Nelson — 2008-06-24

A 42-year-old woman presented to the Emergency Department (ED) with a 1-day history of periumbilical pain migrating to the lower abdomen bilaterally, accompanied by chills and persistent non-bloody, non-bilious emesis. The patient had a history of Cesarean section with bilateral tubal ligation 10 years prior. She had a normal appetite, reported a monogamous sexual history for 20 years, and denied vaginal bleeding. Her last menstrual period was 12 days prior and was followed by 1 day of “yeasty” vaginal discharge.

Aggression and a Show of Force

Wanda Mohr — 2009-08-10

During a literature review I came across an article by Rund et al. in the Journal of Emergency Medicine entitled, “The Use of Intramuscular Benzodiazepines and Antipsychotic Agents in the Treatment of Acute Agitation or Violence in the Emergency Department” (). In it, the authors write that, based on a recent study on the management of acute agitation, one of the strategies recommended is a “show of force” by security personnel. The authors include an algorithm in which “show of force” is a strategy recommended for psychiatric patients (as opposed to patients with medical conditions or substance withdrawal or intoxication).

Reply to Wanda Mohr

Douglas A. Rund, Nicholas Votolato — 2009-10-19

It was our intention to cite the findings of the Expert Consensus Panel for Behavioral Emergencies as support for our recommendation for “show of force.” This recommendation summarizes the recommendations of emergency psychiatrists throughout the country and is clearly outlined in the report by Allen et al. (). In fact, “show of force” occupies a central position in their algorithm regarding treatment of behavioral emergencies (). In our final editing process, we unintentionally attributed this recommendation to an earlier study authored by Allen et al. regarding the use of medication in treating patients with agitated behavior (). We thank the writer for bringing this to our attention.

A Case of Intratracheal Schwannoma Presenting to the Emergency Department With a Diagnosis of Asthmatic Attack: A Clue to Suspect the Cause of Upper Airway Obstruction to Be Other Than Asthma

Mohammed Almarri — 2009-11-18

We have read with interest the article by Erol et al. reporting a case of tracheal schwannoma presenting as acute asthmatic attack (). Schwannoma is a rare cause of upper airway obstruction, often misdiagnosed as asthma, that does not respond to therapy and often presents late in its course, with iatrogenic manifestation of excessive steroid use, such as Cushing's syndrome. Schwannoma rarely presents as acute asthma. Recognition of the cause of the upper airway obstruction is essential to preclude affected patients being prescribed lengthy courses of systemic corticosteroids (). Therefore, relevant points regarding this case are presented to provide clues for when to search for alternate causes of obstruction other than asthma (i.e., asthma imitators).

Response

2009-11-18

We would like to thank Dr. Almarri for his interest in and valuable contributions to our case report. We are setting out our views below to clarify the points raised by Dr. Almarri.

Resident Experience of Abuse and Harassment in Emergency Medicine: Ten Years Later

2008-11-21

Abstract: Background: In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. Objectives: To determine the prevalence of abuse and harassment in a sample of EM residencies. Methods: We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. Results: There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. Conclusion: Abuse and harassment during EM residency continues to be commonplace and is underreported.

No Significant Alteration in Admissions to Emergency Departments During Ramadan

Murat Pekdemir, Murat Ersel, Serkan Yilmaz, Mecit Uygun — 2008-10-09

Abstract: Background: Dietary and lifestyle changes during Ramadan may affect the appearance rate of emergency health problems or increase emergency department (ED) use. Objective: This study's aim was to investigate Ramadan's effects on ED use. Methods: The study group consisted of patients admitted to the ED during Ramadan, and the control group consisted of patients admitted during the 30-day period immediately after Ramadan. The study compared the daily number, diagnosis, and demographic and clinical characteristics of the two groups. Results: The study included 2079 patients. Of these, 1094 (52.6%) were admitted during Ramadan, and the remaining 985 (47.4%) formed the control group. The average number of patients admitted to the ED per day was 36.47 ± 7.9 in the study group and 32.83 ± 5.8 in the control group (p = 0.046). The two groups' demographic and clinical characteristics, such as age, sex, final diagnosis, admission times to ED, and diagnosis, were similar. Conclusions: Our results show that during Ramadan, the clinical features of patients admitted to the ED and the number of ED admissions for specific ailments did not change significantly.

Implementing Electronic Health Records in the Emergency Department

Daniel A. Handel, Jeffrey L. Hackman — 2008-09-15

Abstract: Background: The increasing presence of electronic health records (EHRs) in health care presents interesting and unique challenges in the Emergency Department (ED) setting. Unfortunately, scant literature exists addressing the implementation of EHRs in this setting. Objectives: The authors, both involved in the implementation of such systems at their respective institutions, review the challenges and benefits that exist with such implementation, and the steps that EDs can take to facilitate this process. Discussion: Unlike ambulatory and inpatient settings, where patient volume can be adjusted to help with this transition, EDs are unable to alter their volume and must maximize their efficiency during this process. Conclusions: Understanding and anticipating the EHR's impact on workflow is critical to successful implementation.

Multicenter Survey of Emergency Physician Management and Referral for Hyperglycemia

Adit A. Ginde, Kate E. Delaney, Daniel J. Pallin, Carlos A. Camargo — 2008-07-28

Abstract: Background: The Emergency Department (ED), with its high-risk and often disenfranchised patient population, presents a novel opportunity to identify patients as having undiagnosed or uncontrolled diabetes. Objective: To evaluate Emergency Physician opinion on management and referral for incidental hyperglycemia and on ED-based diabetes screening. Methods: We conducted a web-based survey of all attending and resident Emergency Physicians at three academic EDs. We asked for glucose thresholds to treat and refer non-diabetic and diabetic ED patients for hyperglycemia, comparing physicians' ideal and actual practices. We also inquired about interest in and barriers for active ED-based diabetes screening compared to use of blood glucose values obtained during usual ED care. Results: We contacted 185 physicians, and 152 (85%) completed the survey; 75% of respondents reported routine outpatient referral of non-diabetic patients for random glucose values ≥ 200 mg/dL. However, a majority (71%) believed that they should use a lower threshold to refer than they currently use. Nearly all (92%) agreed that Emergency Physicians should inform non-diabetic patients of elevated glucose values; 53% supported and 21% opposed active ED-based screening of asymptomatic patients. The most commonly cited barriers were limited follow-up (69%), insufficient time/resources (51%), and outside scope of practice (36%). Conclusion: Emergency Physicians support improved recognition of and referral for hyperglycemia, based on glucose values collected during usual ED care. We plan to develop tools to interpret random ED glucose values in the context of undiagnosed and uncontrolled diabetes.

American Academy of Emergency Medicine

2010-02-01

Serum Bilirubin Levels on ICU Admission Are Associated With ARDS Development and Mortality in Sepsis: Zhai R, Sheu CC, Su L, et al. Thorax 2009;64:784–90

Whitney Barrett — 2010-02-01

This study out of Massachusetts General Hospital prospectively enrolled a 1006-patient cohort that was admitted to the intensive care unit (ICU) with the diagnosis of sepsis between September 1999 and November 2006. The purpose of the study was to evaluate the relationship between admission total bilirubin and development of sepsis-related acute respiratory distress syndrome (ARDS). Outcomes were ARDS risk and mortality. All patients admitted to the ICU with the diagnosis of sepsis had total bilirubin measured. Those that developed ARDS then had serial total bilirubin (TB) levels measured for a period of 28 days. Additionally, other biomarkers were drawn and DNA analysis performed to identify those individuals with variations of the gene coding for uridine diphosphate glucurosyltransferase 1A1 (UGT1A1). The gene encoding UGT1A1 is necessary for appropriate glucuronidation of bilirubin and, therefore, bilirubin elimination in humans. Of the 1006 patients in the study, 326 developed ARDS. Hyperbilirubinemia (TB > 2.0 mg/dL) was found in 22.4% of ARDS patients in comparison to 14.1% of patients without ARDS. Patients with hyperbilirubinemia had a greater risk than those with TB < 2.0 of developing ARDS (OR 2.12; p = 0.0007). Twenty-eight-day and 60-day mortality was also higher in those patients with hyperbilirubinemia (OR 2.24; p = 0.020 and OR 2.09; p = 0.020, respectively). Using linear regression to analyze the variations in the gene coding for UGT1A1, researchers established that variants of the UGT1A1 gene contributed to 7.5% of the observed serum TB, and clinical variables explained 29.5%. The authors conclude that, in sepsis, higher serum TB levels are associated with subsequent development of ARDS as well as with increased mortality, and that the majority of that variation was not due to genetic influences.

Biomarkers Improve Mortality Prediction by Prognostic Scales in Community-Acquired Pneumonia: Menendez R, Martinez R, Reyes S, et al. Thorax 2009;64:587–91

Karen Ekernas — 2010-02-01

This prospective cohort study from two hospitals in Spain investigated whether inflammatory markers and cytokine profile measured on admission increase the accuracy of current prognostic scales to predict 30-day mortality from community-acquired pneumonia (CAP). Initial levels of procalcitonin, C-reactive protein (CRP), tumor necrosis factor α, and interleukins IL6, IL8, and IL10 levels were recorded for 453 inpatients. Severity of disease was assessed by the PSI (Pneumonia Severity Index), CURB65 (Confusion, Urea nitrogen, Respiratory rate, Blood pressure, ≥ 65 years of age), and CRB65 (Confusion, Respiratory rate, Blood pressure, ≥ 65 years of age) scales. High levels of CRP and IL6 were found to be independent predictive values for predicting 30-day mortality. Adding CRP to PSI, CURB65, and CRB65 led to significant increases in the area under the receiver operating characteristic curve (AUC) from 0.80 to 0.85, 0.82 to 0.85, and 0.79 to 0.85, respectively. The AUC was greatest (0.88) when using CRP and two severity scales (PSI and CURB65/CRB65). The authors conclude that the addition of CRP to current severity indices improves 30-day mortality prediction and that the highest predictive values are obtained from the use of two scales and CRP.

Identification of Children at Very Low Risk of Clinically-Important Brain Injuries After Head Trauma: A Prospective Cohort Study: Kuppermann N, Holmes JF, Dayan PS, et al. Lancet 2009;374:1160–70

Amanda Kao — 2010-02-01

This prospective cohort study in 25 North American emergency departments (EDs) was designed to derive and validate prediction rules to identify patients < 18 years of age with minor head trauma who are at very low risk for clinically important traumatic brain injury (ciTBI), and in whom computed tomography (CT) may be unwarranted. Investigators identified 42,412 eligible patients with Glasgow Coma Scale scores of 14–15 and conducted standardized assessment in the ED of the enrolled children. At care provider discretion, CT scans were obtained. Study coordinators reviewed records of admitted patients and conducted telephone surveys of released patients to obtain outcome data. By evaluating the injury mechanisms and clinical variables obtained in the initial assessment of the derivation group (33,785 patients), prediction rules for identifying ciTBI were formulated. Validation of the prediction rules was conducted by examining their performance in the validation cohort (8627 patients). In the validation group of children > 2 years old, the prediction rule had a negative predictive value (NPV) of 3798/3800 (99.95%, 95% confidence interval [CI] 99.81–99.99), and sensitivity of 61/63 (96.8%, 95% CI 89.0–99.6). In children < 2 years old, the NPV of the prediction rule was 1176/1176 (100%, 95% CI 99.7–100.0) and sensitivity was 25/25 (100%, 95% CI 86.3–100.0). The authors conclude that their prediction rule accurately predicted risk of ciTBI in their study group, and proper application by clinicians may identify pediatric populations for which CT scans are not needed.

Association Between First-Trimester Vaginal Bleeding and Miscarriage: Hasan R, Baird DD, Herring AH, et al. Obstet Gynecol 2009;114:860–7

Sara Krzyzaniak — 2010-02-01

Vaginal bleeding is a common first-trimester complication of many pregnancies. Most studies that address this topic enroll women who present to the emergency department, selecting for more serious cases of bleeding, which may mark the actual miscarriage event. In comparison, this observational cohort study evaluated bleeding episodes that were temporally separate from miscarriage in 4510 pregnant women. Information about the timing, heaviness, color, and duration of vaginal bleeding was gathered via telephone interviews. Additional information about the presence of pain was also collected. In an effort to control for confounders, the authors excluded bleeding within 4 days of miscarriage. The study demonstrated a strong association between “heavy” bleeding (defined as at least 1 day of bleeding when the flow was as heavy or heavier than the heavy flow of a usual menstrual period) and miscarriage, odds ratio (OR) 2.97 (95% confidence interval [CI] 1.93–4.56). This association was even stronger when the heavy bleeding was accompanied by pain (OR 4.79, 95% CI 2.97–7.73). Conversely, women with “spotting” (bleeding noted only when wiping) or “light bleeding” (lighter than the heavy flow of a usual menstrual period) were not significantly more likely to miscarry than women without bleeding, regardless of whether pain accompanied the bleeding. Adjustments for age, prior miscarriage history, and smoking did not significantly affect the estimates.

Don't Call Me “Mom”: How Parents Want to be Greeted by Their Pediatrician: Amer A, Fischer H. Clin Pediatr (Phila) 2009;48:720–2

Whitney Barrett — 2010-02-01

This study out of Michigan looked at parent and caregiver expectations when being greeted by the child's physician, as well as at how well residents and attendings met those expectations. The study enrolled 100 parents and caregivers at the General Pediatric Clinic at Children's Hospital of Michigan between December 2007 and February 2008. Of the 100 adults who agreed to take part in the study, all were English speaking, 86 were African-American, 81 were the mother of the child. Each individual was asked for his or her expectations concerning shaking hands, being addressed by first name, last name, or both, and physician introducing themselves by first name, last name, or both. Researchers proceeded to ask if the resident and attending (when applicable) met those expectations. Data were analyzed by the Fisher's exact test. Eighty-three percent of adults wanted to shake hands, 87% wanted to be greeted by name (13% by first name, 53% by last name, and 21% by both), and 100% wanted the physician to introduce him or herself (3% by first name, 59% by last, and 38% by first and last). When compared to actual response, 70% of residents (p < 0.05 when compared to adult preference) and 65% of attendings (p < 0.05) shook hands. Residents greeted parents by name 14% of the time (p < 0.001) and attendings 21% (p < 0.001). Residents and attendings introduced themselves by name 84% (p < 0.001) and 93% (p < 0.062) of the time, respectively. The authors conclude that, in this population, parents and caregivers prefer to be greeted with a handshake, by name, and for the child's physician to introduce him or herself by name; however, providers fell short of this expectation, most notably, addressing the adult by name.

Facemasks and Hand Hygiene to Prevent Influenza Transmission in Households: A Cluster Randomized Trial: Cowling BJ, Chan K, Fang VJ, et al. Ann Intern Med 2009;151:437–46

Karen Ekernas — 2010-02-01

Non-pharmaceutical interventions for preventing transmission of the influenza virus have not been well studied. This cluster randomized, controlled trial from Hong Kong investigated the use of hand hygiene and facemasks to prevent household transmission of reverse-transcriptase polymerase chain reaction (RT-PCR)-confirmed influenza. Two hundred fifty-nine households were included in the study; households were randomized to lifestyle education (control, 134 households), hand hygiene among index patients (136 households), or surgical facemasks plus hand hygiene for all household members (137 households). Attack rates among contacts were calculated by RT-PCR or clinical markers after 7 days. Transmission was reduced in 154 households in which interventions were initiated within 36 h of symptom onset in the index patient, an effect driven by fewer infections in the facemask-plus-hand-hygiene group (adjusted odds ratio 0.33; 95% confidence interval 0.13–0.87). The authors conclude that non-pharmaceutical interventions are an important tool in the mitigation of pandemic and inter-pandemic influenza.

Natriuretic Peptides and Troponins in Pulmonary Embolism: A Meta-Analysis: Lega JC, Lacasse Y, Lakhal L, et al. Thorax 2009;64:869–75

Amanda Kao — 2010-02-01

This meta-analysis was designed to evaluate the association of natriuretic peptides with prognosis in acute pulmonary embolus (APE) alone and in conjunction with troponins, as well as their association with right ventricular dysfunction. Search of MEDLINE and EMBASE databases and conference abstracts before February 2008 yielded 222 studies from which 23 studies (enrolling 1127 total patients) were selected for inclusion in the meta-analysis based on ability to construct a 2 × 2 table using natriuretic peptide results and one or more of the outcomes of interest. The final analysis showed significant association of elevated natriuretic peptide levels with all-cause mortality (odds ratio [OR] 6.2; 95% confidence interval [CI] 3.0–12.7), APE-related mortality (OR 5.0; 95% CI 2.2–11.5), and serious adverse outcomes (OR 6.7; 95% CI 3.9–11.6). Although study heterogeneity limited analysis, N-terminal pro-B-type natriuretic peptides appeared less sensitive and specific than B-type natriuretic peptides in detection of right ventricular dysfunction. In patients with raised natriuretic peptide levels, analysis found increased troponins to be a significant independent prognostic marker associated with further elevated risk in all-cause mortality (OR 6.9; CI 2.3–20.7), and APE-related mortality (OR 8.4; CI 2.1–33.4), but not in serious adverse events (OR 15.5; CI 0.8–284.7). The authors conclude that patients with APE and elevated natriuretic peptide levels with or without elevated troponins are at increased risk of adverse outcomes.

Predicting Deep Venous Thrombosis in Pregnancy: Out in “Left” Field? Chan WS, Less A, Spencer F, et al. Ann Intern Med 2009;151:85–92

Sara Krzyzaniak — 2010-02-01

Pregnant women are at inherently higher risk for deep venous thrombosis (DVT) but have traditionally been excluded in studies looking at clinical signs and symptoms of DVT. This cross-sectional study enrolled 194 pregnant women suspected of having DVT. Each woman was assessed by a thrombosis expert who assigned a pretest probability (low, moderate, or high) and recorded presence of 11 clinical variables thought to be associated with DVT. Each patient underwent compression ultrasonography (US). If the initial US was negative, the patient had 3 months of clinical follow-up to ensure there was no DVT present; some women with initial negative imaging had repeat US on days 3 and 7, along with 3-month follow-up. Twelve women were diagnosed with DVT on initial imaging. Of the 182 patients with negative initial US, 152 had serial testing, resulting in four subsequent diagnoses of DVT. Among the 30 patients who did not have serial imaging, one received a diagnosis of DVT during the 3-month follow-up period. In total, 17 patients (8.8%) were diagnosed with DVT. Three clinical variables were found to be significantly associated with presence of DVT: symptoms in left leg (odds ratio [OR] 44.28, 95% confidence interval [CI] 3.22–609.69), calf circumference difference ≥ 2 cm (OR 26.89, 95% CI 6.10–118.54), and first trimester presentation (OR 53.43, 95% CI 7.12–401.02). Additionally, a clinician's assessment of low pretest probability for presence of DVT was associated with a negative predictive value of 98.5% (95% CI 94.6%–99.6%), whereas the likelihood ratio for a non-low pretest probability was 3.4 (95% CI 2.5–4.5).

Impact of Motorcycle Helmets and State Laws on Society's Burden: A National Study: Croce MA, Zarzaur BL, Magnotti LJ, et al. Ann Surg 2009;250:390–4

Whitney Barrett — 2010-02-01

This study used the National Trauma Data Bank (NTDB) to study multiple aspects of motorcycle collisions (MCC) and helmet use. End points included helmet use in states with mandatory helmet laws, resource utilization of helmeted vs. unhelmeted motorcyclists, and overall mortality of helmeted vs. unhelmeted motorcyclists. Overall in-hospital mortality was the primary study outcome. Data were from the NTDB from 2002–2007, and inclusion criteria were documented MCC, documented helmet use, data to evaluate injury severity score (ISS), resource utilization, and final diagnosis. There were 76,944 patients that qualified for the study. Population means were: age 36 years, admission Glasgow Coma Scale score 13.7, admission ISS 13.5, and 76% helmet use. In the categories of head, face, and cervical spine injuries, helmeted patients had statistically less severe injury patterns than unhelmeted patients (p < 0.0001). There was no statistical difference in rate of injury of other body regions or in rate of spinal cord injury. Estimated intensive care unit (ICU) savings per patient with helmet use was $1750 based on average length of ICU stay only. Finally, extensive statistical analysis of the data using logistic regression to isolate the effect of helmet use on mortality in the setting of multiple covariates indicated that helmet use had a strong protective effect on in-hospital mortality. Additionally, data were analyzed for helmet use in states with mandatory helmet laws in comparison to those states with partial and no laws, the results of which were 90%, 61%, and 53%, respectively. Based on the data, the authors conclude that unhelmeted motorcyclists suffer more severe brain injuries, have longer ICU stays and associated increased resource utilization, and that mandatory helmet laws increase the percentage of motorcyclists that wear helmets.

The Association Between Iron Deficiency and Febrile Seizures in Childhood: Hartfield DS, Tan J, Yager JY, et al. Clin Pediatr (Phila) 2009;48:420–6

Karen Ekernas — 2010-02-01

This retrospective case control study analyzed the association between iron deficiency and febrile seizures among children aged 6 to 36 months. The iron status of 361 patients who presented to the emergency department with febrile seizures was compared with 390 otherwise healthy controls who presented with febrile illness without seizure. Iron status was determined by mean corpuscular volume, red blood cell distribution width, and hemoglobin level. The study found that 9% of cases had iron deficiency (ID) and 6% had iron deficiency anemia, compared to 5% and 4% of controls, respectively, with a conditional logistic regression odds ration for ID in febrile seizure patients of 1.84 (95% confidence interval 1.02–3.31). The authors suggest that ID screening should be considered in children presenting with febrile seizure.

Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU: Levin PD, Shatz O, Sviri S, et al. Chest 2009;136:426–32

Amanda Kao — 2010-02-01

Four phases were included in this study to examine infection control procedures, the transfer of resistant bacteria to radiographic equipment, and the effect of improved infection control training on transmission. In the intensive care unit (ICU) at a 750-bed tertiary referral medical center, 14 infection control measures were observed as technicians obtained chest radiographs of ICU patients and then cultures of equipment were obtained by aseptic technique. The 4-month intervention period consisted of daily personal discussions with technicians to reinforce appropriate behaviors. Surveillance of infection control measures were continued for an additional month in the follow-up period. Data from all periods were compared using the Student's t test, and the chi-squared or Fisher's exact tests, as appropriate. Results showed that adequate infection control was practiced in two of 173 radiographs (1%) in the observation period, 48 of 113 (42%; p < 0.001) in the intervention period, and 12 of 120 (10%; p < 0.001) follow-up period radiographs. Surface cultures of radiographic equipment yielded resistant bacteria in 12 of 30 occasions (39%), 0 of 29 occasions, and 7 of 14 (50%) occasions in the observation, intervention, and follow-up periods, respectively. The authors concluded that: obtaining radiographs in the ICU is likely involved in cross-infection of resistant bacteria, improved infection control technique decreases its occurrence, and consideration of this factor should be included when infection control practices are evaluated and instituted.

Safety of Propofol Sedation for Pediatric Outpatient Procedures: Larsen R, Galloway D, Wadera S, et al. Clin Pediatr 2009;48:819–23

Sara Krzyzaniak — 2010-02-01

Propofol is frequently used for sedation in both inpatient and outpatient pediatric procedures. Most available studies demonstrate its safety when given by Anesthesiology staff. This retrospective study examined the safety of propofol for sedation when administered by pediatric intensivists. In total, 4716 procedures over a 6-year period were included in this study.

Calendar of Events

2010-02-01